Authorization for a
Small Sum Cash Withdrawal
From 457(b) Deferred Compensation Plan
Group Supplemental Retirement Annuities
Small Sum Cash Withdrawals...at a Glance
Before you return this form, please read the following information. If you have questions or need
additional assistance, please call our Telephone Counseling Center at 800 842-2776, Monday to Friday
from 8 a.m. to 10 p.m. ET, and Saturday from 9 a.m. to 6 p.m. ET.
Eligibility for a Small Sum Cash Withdrawal
You may elect to receive a small sum distribution if: the amount in your account does not exceed $5,000
(or the dollar limit under the Internal Revenue Code, if greater); you have not previously received a
small sum distribution under the plan; and no amounts were deferred to your accounts under the plan
during the two-year period ending on the date of the small sum distribution.
How Much You Can Withdraw
You can withdraw all or part of your account, as permitted by your employer’s plan.
Completing the Withdrawal Form
If you are eligible to obtain a Small Sum Cash Withdrawal, you and your employer have to complete
the enclosed Authorization for a Small Sum Cash Withdrawal From 457(b) Deferred Compensation Plan
Group Supplemental Retirement Annuities form.
Electronic Funds Transfer
You can get your payment faster with electronic funds transfer (EFT). If you complete a Direct
Deposit Authorization on the Payment Destination Instructions form (which can be downloaded at
www.tiaa-cref.org), we’ll transfer your payment to your bank account electronically. You won’t have to
worry about postal delays or checks getting lost or stolen.
Effective Date of Payment
Your withdrawal will be effective the day we receive your completed forms and your withdrawal will be
sent shortly after that.
Income Tax Withholding
Federal law requires us to withhold 20% of the taxable portion of your payment.
F10788 11-02
457(b) Public
Authorization for a Small Sum Cash Withdrawal
From 457(b) Deferred Compensation Plan
Group Supplemental Retirement Annuities
1. PERSONAL
INFORMATION
Please complete
this section.
Name
Social Security Number
Daytime Telephone
Citizenship (if other than U.S.)
TIAA Number
CREF Number
Name of Employer
2. AMOUNT
OF PAYMENT
Please tell us how much you
want to withdraw. You can
request the full or partial
available amount (a minimum
withdrawal of $1,000 is
required), as permitted by
your employer’s plan.
■ I want to withdraw 100% of my account.
3. SUBSTITUTE
FORM W-9
If you are a U.S. person
(i.e., a U.S. citizen, or a
non-U.S. citizen who
resides in the U.S.), please
read and sign this section.
Under penalties of perjury, I certify that the taxpayer identification number shown
on this form is my correct Social Security number; and I am not subject to
backup withholding due to failure to report interest and dividend income; and I
am a U.S. person.
If you are a non-U.S. citizen
who resides outside the
U.S., do not complete this
section. You must complete
form W-8BEN.
4. PARTICIPANT
CERTIFICATION
You must sign this form
if you are eligible for a
Small Sum Cash
Withdrawal.
■ I want to withdraw $____________________.
Signature
Date
I certify that: I have not previously received a small sum distribution under the
plan and no amounts have been deferred to my accounts during the two-year
period ending on the date of the small sum distribution.
Signature
Date
YOUR
SIGNATURE
5. EMPLOYER
AUTHORIZATION
I certify that (name of participant)
is eligible for a small sum cash withdrawal.
I understand that by signing I am approving this distribution.
Signature of Authorized Representative
Date
Title
Name of Institution
1 of 1
TAECJ
F10788 11-02
Small Sum Distribution
Telephone Number
457(b) Public
For your protection, some states require a warning against fraud to appear on this form. These states,
including but not limited to Alaska, Arizona, Arkansas, California, Delaware, Indiana, Kentucky,
Minnesota, New Hampshire, New Mexico, New York, Ohio, Oklahoma, and Pennsylvania, as well as
the District of Columbia, require a warning substantially similar to the following:
People who file applications for insurance or statements of claim commit a fraudulent insurance
act if they:
•
knowingly do so with intent to injure, defraud, or deceive any insurance
company or another person; and/or
•
knowingly include in their application or statement of claim any
materially false or misleading information; and/or
•
knowingly conceal information for the purpose of misleading
concerning any fact material to the application or claim.
Insurance fraud is a crime and in some states it is a felony. Penalties may include imprisonment,
fines, denial of insurance, and civil damages.
New York residents, please note: Civil penalties shall not exceed $5,000 and the stated value
of the claim for each such violation.
Colorado residents, please note: Any insurance company or any agent of an insurance company
who knowingly provides false, incomplete, or misleading facts or information to a policyholder
or to a claimant for the purpose of defrauding or attempting to defraud the policyholder or the
claimant with regard to a settlement or award payable from the insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Florida residents, please note: Any person who knowingly and with intent to injure, defraud, or
deceive any insurer files a statement of claim or an application containing any false, incomplete,
or misleading information, is guilty of a felony of the third degree.
New Hampshire residents, please note: Prosecution and punishment for insurance fraud
are provided by RSA 638.20.
New Jersey residents, please note: Any person who knowingly files a statement of claim
containing any false or misleading information is subject to criminal and civil penalties.
F10788 11-02